Sedation Woes...

What do you use routinely for sedation on patiently requiring mechanical ventilation? Our first line routine is fentanyl @ 1mcg/kg/hr and midazolam at 1mcg/kg/min and we increase as patient needs to illicit acceptable sedation. The unit I work in has a large population of transplant patients that get sick and are readmitted, required ventilation, but have a great tolerance to drugs. Our institution allows for Precedex infusions of no longer than 24 hours (bummer!). I've seen them switch to a ketamine gtt( and the kids freak if there's no benzo on board as well), pentobarbital gtt (love!), and all the PRNS under the sun: lorazepam, chloral hydrate. We use paralyzingly agents only if indicated, but as we know this isn't a sedative. Any input greatly appreciated!

What about Propofol? I have used Propofol and have found it easy to use, few deleterious effects (overall),and effective. I am not a big fan of Ketamine for kids.

Feb 9, '12

The only time we use propofol is SOMETIMES in the 12 or so hours prior to planned extubation since the half life is so short. I know the adult units use it more often, but our intensivists don't use propofol regularly.

Feb 9, '12

Propofol should not be used for children for any interval longer than 24 hours. They're at very high risk for PRIS (propofol-related infusion syndrome):
"Propofol-related infusion syndrome (PRIS) is a rare yet often fatal syndrome that hasbeen observed in critically ill patients receiving propofol for sedation. PRIS is characterized by severe unexplained metabolic acidosis, arrhythmias, acute renal failure, rhabdomyolysis, hyperkalemia, and cardiovascular collapse. Although the exact pathophysiology of PRIS remains to be determined, impaired tissue metabolism caused bypropofol infusion appears to be an important mechanism leading to complete cardiovascular collapse. Risk factors for developing PRIS include sepsis, severe cerebral injury, and high propofol doses. Early recognition of the manifestations is the key to managing PRIS. If PRIS is suspected, propofol should be discontinued and an alternative sedative agent initiated. General measures to support cardiac and renal function should be initiated promptly in patients with suspected PRIS."http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/MikeArticle.pdf

I've seen a peds patient die from this. Never want to go there again...

We've run Precedex for weeks at a time on some of the same sort of patients the OP described with no significant issues.

Feb 12, '12

Same reason we don't use it in children in our unit as janfrn stated. Seen it in three adults so far and it is one scary syndrome. Patient is fine one moment starts to crash out of the blue the next and is usually dead within a few hours with fluids and pressors running while you are desperately trying to get an ECMO in...

Feb 13, '12

We use fentanyl and versed as well (although versed not as much anymore because of effects on brain development per our intensivists). On a lot of kids that have been sedated a long time we give scheduled doses of methadone and ativan. I was surprised to have a kid on a pentobarb gtt the other day because we don't use it that often, but she loved it!

We use fentanyl and versed as well (although versed not as much anymore because of effects on brain development per our intensivists). !

If you have any articles (anything in writing) about that I would love to read them, that would totally revamp what is being done on our unit since 90% of pt's are on versed at some point for various periods of time. Thank you for bringing it up

Feb 13, '12

Just google midazolam apoptosis or midazolam brain development (or anything along those lines) and a slew of articles comes up. A lot of the studies are on infant mice, but some feel that they are applicable to humans as well.

That's not to say that we don't use versed anymore. A few of the intensivists are trying to use precedex when they can, but we have the 24 hour limit too. I have only heard about the apoptosis thing from one of the docs.

Apr 2, '12

Our usual gtts are also fent and versed, with precedex often being the next added agent if needed and of course the pt doesn't brady on us. We don't have a 24 hour rule with precedex, only with propofol for the reason mentioned above so it is only used generally for preparing for extubation, or if child requires short term intubation for an MRI for example. I've also (just recently) heard of the apoptosis study and then had a pt where we added precedex for the sole reason of being able to decrease the versed gtt. Some of our long term kids with tolerances that a bus of junkies couldn't match, we switch over to morphine or dilaudid gtts instead of using fentanyl. We very rarely use pentobarb gtts but it isn't too uncommon to see it in the list of prns. Also as mentioned above, we start our kids on either methadone/ativan weans, or substitute valium in for the ativan if they have been on sedation for any length of time. Paralytics, now that's a whole different beast...

Apr 4, '12

Do you increase these doses? These are starter doses and most of our intubated patients wouldn't last very long at these rates. We start with 0.1mg/kg/hr of Versed and 1 mcg/kg/hr Fentanyl, bolus and increase as needed. It depends on the dr where we end and add in other drugs, up to 0.25-0.3 mg/kg/hr of Versed, maxing out about 7mg/hr. Fentanyl about 2.5mcg/kg/hour. In general, next we go to Precedex gtts.

If they've been intubated for several days, we'll start Ativan and Methadone as we're getting ready to extubate for withdrawal.

What do you use routinely for sedation on patiently requiring mechanical ventilation? Our first line routine is fentanyl @ 1mcg/kg/hr and midazolam at 1mcg/kg/min and we increase as patient needs to illicit acceptable sedation. The unit I work in has a large population of transplant patients that get sick and are readmitted, required ventilation, but have a great tolerance to drugs. Our institution allows for Precedex infusions of no longer than 24 hours (bummer!). I've seen them switch to a ketamine gtt( and the kids freak if there's no benzo on board as well), pentobarbital gtt (love!), and all the PRNS under the sun: lorazepam, chloral hydrate. We use paralyzingly agents only if indicated, but as we know this isn't a sedative. Any input greatly appreciated!

Apr 7, '12

Pentobarbital for sedation? Interesting. I work with adults, but we use pentobarb to induce coma (literal, no cough, gag, movement, corneals, etc...) for refractory status

Apr 10, '12

Typically precedex + an analgesic and midazolam. I've read about precedex drips having a 24 hr limit at other facilities but our facility sometimes has patients on precedex for weeks.